August 2015

Taller, heavier children have heightened Sever disease risk

Long-term pain warrants early ID

By Katie Bell

Children presenting with calcaneal apo­phy­sitis (Sever disease) are anthropometrically different from their peers and experience a lengthy period of pain, according to Australian study findings that underscore the importance of early intervention and a holistic management approach in this patient population.

“I think this study highlights the importance of looking at the entire child, not just their foot,” said study author Alicia James, BPod, MHealth Sci, director of the Kingston Foot Clinic in Cheltenham, Australia.

The researchers set out to identify any association between the pain experienced from Sever disease, anthropometric data, and lower limb measurements. The cross-sectional study, which was part of a wider randomized comparative efficacy trial, enrolled 124 children (72 boys) with Sever disease aged between 8 and 14 years. Measures of height, weight, waist circumference, body mass index (BMI), foot posture, and ankle joint range of motion were recorded and compared with normative values. Pain was assessed using a visual analog scale.

Compared with normative values, children with Sever disease were taller, heavier, and had a higher mean BMI. Sever disease was also associated with a higher foot posture index, indicative of greater pronation, and greater ankle joint range of motion compared with normative values.

The foot and ankle findings are more likely to be contributing factors than compensatory factors, James said. The finding of increased ankle range of motion contrasts with a 2011 study and contradicts the theory that passive tension in the gastrocnemius-soleus complex contributes to Sever disease in taller children. Instead, James and colleagues hypothesized, it may be that the physiology of the apophy­sis in taller children may increase its vulnerability to the stresses involved in physical activity.

“I believe this finding has the greatest influence on our treatment regimes when considering previous literature,” James said.

Joanna Conway, BSc Podiatry, SRCh, MChs, Senior Podiatrist at the Royal Orthopaedic Hospital in Birmingham, UK, noted though foot and ankle variables can contribute to Sever disease, the possibility of compensatory foot and ankle issues should not be overlooked.

“The pain of calcaneal apophysitis can cause further problems, such as a limp on the affected side. This will further alter the child’s gait as they try to avoid the pain, and this can cause further musculoskeletal and biomechanical issues,” Conway said.

The study, which was epublished in May by the Journal of Pediatrics, also found older participants and those who had experienced longer durations of pain reported higher levels of pain severity.

“This study for me has highlighted the duration of pain these children can endure. The mean length of time the children experienced pain before they contacted us for the study was ten months, and we found pain increased as the child increased in age. I believe this encourages intervention at presentation,” James said. “We must explain to parents that, while the growth plate remains open, monitoring and treatment will assist in pain relief. Once the growth plate has closed, and only then, complete pain resolution will be achieved.”

Conway agreed that early intervention is essential.

“In children where it is undiagnosed over a long period of time, I have seen the condition worsen, and often activity levels decrease, which can be difficult for a child who is involved in team sports,” she said. “Early intervention is key to treating these patients due to their high activity levels. Also, multidisciplinary treatment is advantageous.”

Although the authors were not able to determine if BMI was a causative factor for Sever disease or a result of pain-related inactivity, the anthropometric findings suggest early management of the condition with weight loss through diet and cushioned shoes for better shock absorption can help decrease the intensity and duration of pain, James said.

Interventions involving stretching, heel raises, and foot orthoses may also be warranted, she said, but should be considered in the context of the child as a whole.

“Such interventions are reported to assist in the pain relief and clinically likely do, but I believe this [study] supports a thorough assessment prior to prescribing your intervention,” James said. “[The results] encourage the clinician to treat the entire child and to assess each child individually rather than following a previous script we may have developed due to university training or opinion pieces.”